BackgroundPulmonary Rehabilitation for moderate Chronic Obstructive Pulmonary Disease in primary care could improve patients’ quality of life.MethodsThis study aimed to assess the efficacy of a 3-month Pulmonary Rehabilitation (PR) program with a further 9 months of maintenance (RHBM group) compared with both PR for 3 months without further maintenance (RHB group) and usual care in improving the quality of life of patients with moderate COPD.We conducted a parallel-group, randomized clinical trial in Majorca primary health care in which 97 patients with moderate COPD were assigned to the 3 groups. Health outcomes were quality of life, exercise capacity, pulmonary function and exacerbations.ResultsWe found statistically and clinically significant differences in the three groups at 3 months in the emotion dimension (0.53; 95%CI0.06-1.01) in the usual care group, (0.72; 95%CI0.26-1.18) the RHB group (0.87; 95%CI 0.44-1.30) and the RHBM group as well as in fatigue (0.47; 95%CI 0.17-0.78) in the RHBM group. After 1 year, these differences favored the long-term rehabilitation group in the domains of fatigue (0.56; 95%CI 0.22-0.91), mastery (0.79; 95%CI 0.03-1.55) and emotion (0.75; 95%CI 0.17-1.33). Between-group analysis only showed statistically and clinically significant differences between the RHB group and control group in the dyspnea dimension (0.79 95%CI 0.05-1.52). No differences were found for exacerbations, pulmonary function or exercise capacity.ConclusionsWe found that patients with moderate COPD and low level of impairment did not show meaningful changes in QoL, exercise tolerance, pulmonary function or exacerbation after a one-year, community based rehabilitation program. However, long-term improvements in the emotional, fatigue and mastery dimensions (within intervention groups) were identified.Trial registrationISRCTN94514482

The phenotypic characteristics of chronic obstructive pulmonary disease (COPD) in individuals younger than 50 years of age (early COPD) are not well defined. This prospective, multicentre, case–control study sought to describe these characteristics and compare them with those of smokers (≥10 pack-years) of similar age with normal spirometry (controls).We studied 92 cases (post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <0.7) and 197 controls. Results were contrasted with participants with similar inclusion criteria recruited into the ECLIPSE and COPDGene cohorts.Cases had moderate airflow limitation (FEV1 71.3±20.8%) but were often symptomatic, used healthcare resources frequently, had air trapping (residual volume 150.6±55.5% ref.), had reduced diffusing capacity (84.2±20.7% ref.) and had frequent evidence of computed tomography (CT) emphysema (61%). Of note, less than half of cases (46%) had been previously diagnosed with COPD. Interestingly, they also often reported a family history of respiratory diseases and had been hospitalised because of respiratory problems before the age of 5 years more frequently than controls (12% versus 3%, p=0.009). By and large, these observations were reproduced when available in the ECLIPSE and COPDGene cohorts.These results show that early COPD is associated with substantial health impact and significant structural and functional abnormalities, albeit it is often not diagnosed (hence, treated). The fact that a sizeable proportion of patients with early COPD report a family history of respiratory diseases and/or early-life events (including hospitalisations before the age of 5 years) renders further support to the possibility of early-life origin of COPD.

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Abstracts Gregory L. Moneta, MD, Section Editor Atherosclerotic Plaque Composition and Occurrence of Restenosis After Carotid EndarterectomyHellings WE, Moll FL, De Vries JP, et al. JAMA 2008;299:547-54. Conclusion: Lipid-rich inflammatory plaques are associated with a reduced risk of restenosis after carotid endarterectomy. Summary: Both clinical and angiographic criteria have been used to try to determine the risk of restenosis after a vascular intervention. The authors of this study evaluated the composition of the atherosclerotic plaque at the intervention site in terms of plaque features that may be related to carotid restenosis after carotid endarterectomy. There were 500 patients prospectively followed up between April 1, 2002, and March 14, 2006. Patients were assessed for carotid artery restenosis as measured by duplex ultrasound imaging 1 year after intervention. A Ͼ50% stenosis was defined as a peak systolic velocity of Ͼ125 cm/s and a Ͼ70% stenosis was defined as a peak systolic velocity of Ͼ230 cm/s. Carotid restenosis after carotid endarterectomy was determined with predefined histologic plaque characteristics. These included macrophage and smooth muscle cell infiltration, collagen, calcification, interplaque hemorrhage, luminal thrombus, and lipid core size. Comparisons were determined using multivariate logistic regression analysis and were adjusted for clinical characteristics.At 1 year, 85 patients (17%) had developed Ն50% carotid restenosis, and 40 (8%) developed Ն70% restenosis. Histologic examination of the plaque revealed that increased macrophage infiltration (n ϭ 286) had a lower risk of Ն50% restenosis than plaques with no or minor macrophage infiltration (n ϭ 215; 11.5% vs 24.3%; adjusted odds ratio [OR], 0.43; 95% confidence interval [CI], 0.26-0.72). Patients with higher macrophage infiltration also had a lower risk of developing Ն70% restenosis (4.5% vs 12.6%; adjusted OR, 0.36; 95% CI, 0.17-0.74). The 177 patients whose plaque had a lipid core that was Ͼ40% of plaque volume also had a lower risk of Ն50% restenosis than the 94 patients with a lipid core size of Ͻ10% (11.3% vs 25.5%; adjusted OR, 0.40; 95% CI, 0.19-0.81). A large lipid core also had a lower risk of developing Ն70% restenosis (5.6% vs 14.9%; adjusted OR, 0.42; 95% CI, 0.17-1.04).Comment: Many of the findings of this study are unexpected. Plaque characteristics of inflammation and higher lipid content, commonly thought to be associated with more dangerous plaques were, in this study, associated with lower rates of restenosis after carotid endarterectomy. Their other findings also seem in opposition to previous studies or prevailing opinion. For example, an incidence of 21% of Ͼ50% restenosis with Dacron patch angioplasty at 1 year is higher than usually reported. Also, vein and Dacron patches are not generally regarded as having much difference in their ability to prevent restenosis after carotid endarterectomy, but this study found vein patches were more much effective in preventing restenosis than Dacron patches. Th...

Aims: We describe the set-up of a population-based study focussed on respiratory conditions, and describe a pilot study -the PULmons SAns Illes Balears (PULSAIB) study -aimed at investigating the natural history of COPD, obstructive sleep apnoea (OSA), and other common chronic diseases.Methods: A cross-sectional study was designed to survey two fieldwork areas, one rural and one urban, in the Balearic Islands, Spain. Tests conducted included a questionnaire, spirometry with post-bronchodilator (PBD) test, and portable respiratory polygraphy. Results:We assessed all processes and tools to be used, and piloted them in 175 participants from Bunyola (rural) and 130 participants from the Son Pizà area (urban). Within this first cross-sectional assessment of the Balearic population aged 30 to 80 years, we report the prevalence of airflow limitation defined as a PBD FEV1/FVC ratio <0.7 and the prevalence of OSA defined as an apnoea-hypopnoea index (AHI) >10/hour. Conclusion:A cohort study in the Balearic population to investigate the natural history of COPD and OSA is feasible.